Healthcare Provider Details

I. General information

NPI: 1871922807
Provider Name (Legal Business Name): BEAR CANYON ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 MONTGOMERY NE STE 2-D
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

10151 MONTGOMERY NE STE 2-D
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-3400
  • Fax: 505-292-7124
Mailing address:
  • Phone: 505-292-3400
  • Fax: 505-292-7124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberDD3881
License Number StateNM

VIII. Authorized Official

Name: DR. TRAVIS CHARLES RUDD
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-292-3400